Grievance - Mediation Request

DEPARTMENT OF HOMELAND SECURITY

Transportation Security Administration

GRIEVANCE – MEDIATION REQUEST

INSTRUCTIONS: This request is to be used to file a grievance and/or mediation request in accordance with TSA Human Capital Management (HCM)policy, HCM Letter 771-4, National Resolution Centerand related Handbook. TSA’s internal grievance process is a formal written grievance to a local Designated Grievance Official (DGO). You must file within 15 calendar days of the action or decision being grieved or from when you first learned or may have been reasonablely expected to learn of the decision or action. Filing instructions and time limits are found in HCM 771-4 Handbook. This form must be submitted to the National Resolution Center (NRC) at or faxed to (703) 603-4057. Include all information and documentation specific to this Grievance - Mediation Request.
NOTE: This form is to be used for grievances related to workplace disputes and disciplinary actions beginning January 6, 2013.It is the employee’s obligation to provide all necessary information and documentation in support of the grievance as required by the NRC. Failure to comply with these instructions could result in delay of processing and/or the dismissal of the grievance.
SECTION I. Employee Information
Date of Request: / / / Date Grievable Actionor Decision: / /
Name:
Airport Code/Office:
Current Position:
Include Occupational Series & Pay Band (e.g., TSO, 1802, D Band)
Phone Number: / () - / Email Address:
SECTION II. Action Requested (check one)
I am filing a Grievance andI am interested in Mediation / I am filing a Grievance andI am NOTinterested in Mediation / I am interested in Mediation only
SECTION III.Other Forms of Resolution Sought(Check all that apply)
Office of Professional Responsibility(OPR)
TSES Executive Review Board (ERB)
Merit Systems Protection Board (MSPB) / Interest Based Conversation
Peer Review / Office of Civil Rights and Liberties, Ombudsman and Traveler Engagement (CRL/OTE), Civil Rights Division (CRD)
Other:
SECTION IV.Grievance Information
Action/occurrence giving rise to the grievance:
The remedy or personal relief sought:
SECTION V. Designation(personal representative)
NOTE: TSA Form 1163-1, Personal Representative Designation must be completed and attached.
Name (if any):
Position/Title: / E-mail Address:
Phone Number: / () - / TSA Employee AFGE Representative Other:
SECTION VI.Acknowledgement
I understandany allegation of prohibited discrimination will not proceed through TSA’s Grievance – Mediation procedures. Such allegations must be submitted to CRL/OTE, Civil Rights Division. I affirm the information on this form is accurate to the best of my knowledge and belief.
(Employee’s Signature) / (Date)
SECTION VII. National Resolution Center Use Only
Date Received: / by (check one): E-Mail Fax Other:
Received by: / Case Number:
(Print Name)

PRIVACY ACT STATEMENT: AUTHORITY: 49 U.S.C. 114(n)authorizes the collection of this information. PRINCIPAL PURPOSE(S): TSA will use this information in the investigation and resolution of your grievance. ROUTINE USE(S): This information may be shared with official at the Merit Systems Protection Board, the U.S. Office of the Special Counsel, the Equal Employment Opportunity Commission, and/or any other agency or office when in performance of their official duties. Sharing is governed by System of Records Notice DHS-ALL-018 Grievances, Appeals, and Disciplinary Action. DISCLOSURE: Voluntary. Failure to provide this information could result in a delay or inability to resolve your grievance.

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